- How do benzodiazepines work?
- What is benzodiazepine dependence?
- How long does withdrawal from benzodiazepines take to get over?
- What are the different ways to detoxify from benzodiazepines?
- What is the Rapid Benzodiazepine Detoxification (RBD) program?
- What is Flumazenil therapy and why is it important?
- Are there any risks and side effects?
- How do patients feel during the detox?
- What happens after the detoxification?
How do benzodiazepines work?
The Benzodiazepines are powerful drugs that attach to the Gamma-Aminobutyric Acid (GABA) receptors in the brain. The GABA system in the brain is part of our "sedation" or calming down system. The GABA system helps us to feel calm and relaxed when we are under stress or feeling any upset. In the normal situation, whenever we feel anxiety or stress, we all produce extra GABA molecules and this extra GABA attaches to our GABA receptors. This helps us feel calm and relaxed. It can also help us to sleep.
What is benzodiazepine dependence?
Benzodiazepine dependence is a condition where people have been taking these benzodiazepine drugs and the body has become physically dependent on them. This dependence usually happens within a period of weeks or months. When patients take any kind of benzodiazepine the body essentially shuts down its own GABA production and then the body has very limited ability to feel calm or relaxed. If the person stops taking their benzodiazepine, or even starts weaning off, patients feel severe anxiety and restlessness. Symptoms of benzodiazepine withdrawal include agitation, anxiety, panic, flushed feeling, increased pulse rate, increased blood pressure, sweating, and insomnia. The symptoms can even progress to seizures, confusion, and a loss of contact with reality. Some patients have a relatively easy withdrawal, but for others it can be a very difficult process.
How long does withdrawal from benzodiazepines take to get over?
There are two phases to benzodiazepine withdrawal:
- Acute phase - lasting 7 days to 90 days
- Post Acute Withdrawal Syndrome (PAWS) â€“ lasting up to 2 years
The length of time to get completely free of the benzodiazepines varies according to the benzodiazepine that the patient was taking. A short acting drug like Xanax has a short acute withdrawal phase, usually lasting around 7 days. A long acting benzodiazepine like Klonopin can have acute withdrawal symptoms that last 90 days.
The Post Acute Withdrawal Syndrome (PAWS) is usually mild and essentially consists of a slight increase in anxiety and insomnia. Patients find themselves worrying more than they need to, but over time this goes away. The symptoms can usually be helped with a combination of counseling, support, and sometimes non-addictive medicines.
What are the different ways to detoxify from benzodiazepines?
The acute benzodiazepine withdrawal takes so long that it is almost never performed in a hospital. Insurance companies usually donâ€™t want to pay for patients to stay in a hospital long enough to complete the withdrawal.
The withdrawal method that most doctors recommend is for patients to wean down from the benzodiazepine that they are taking. Sometimes doctors will switch from one benzodiazepine to a longer acting one such as Klonopin, to try to make this process easier. Doctors will usually try to get their patients to wean down by about 10% per week. This means the detox may be able to be completed in about 10 weeks. Unfortunately this slow taper is almost never successful. The withdrawal symptoms are just so strong that most patients are unable to tolerate them. Most patients suffer with severe anxiety, increased insomnia and panic attacks. They feel so bad that usually they go back up on their dose. Success rates of tapering benzodiazepines are very low, probably less than 20%.
What is the Rapid Benzodiazepine Detoxification (RBD) program?
This program uses an accelerated detoxification method that can complete the withdrawal process in about 7 days. The patient stops their benzodiazepines, and is started on an infusion of Flumazenil. The Flumazenil provides very good relief for the withdrawal symptoms and at the same time actually removes the benzodiazepines from the patientâ€™s body. The patient may stay in a hospital for part or all of the treatment, but most patients feel more comfortable and can safely complete the detox at home. All patients must have a support person who will be with them throughout the detox. During the whole period they usually remain comfortable and at the end of 7 days they are free of the benzodiazepines.
What is Flumazenil therapy and why is it important?
Flumazenil attaches tightly to the benzodiazepine receptors. It is called a â€œpartial agonistâ€ and a â€œpartial antagonistâ€. This means that the Flumazenil goes to the GABA receptors and binds so tightly to them that it actually displaces or pushes away any other benzodiazepines that the patient was taking. It then also turns on the switch very lightly and so it provides some relief of withdrawal symptoms. It seems to stabilize the receptors so that patients feel comfortable and have minimal withdrawal symptoms. Interestingly, some clinicians believe that the Flumazenil actually re-sets the GABA receptors, back to a normal state, so that after the therapy is completed most patients seem to lose their desire for any benzodiazepines. They also seem to lose a lot of their their anxiety and panic symptoms. It is fairly easy for most patients to stay off the benzodiazepines. In this way it seems to greatly reduce the PAWS that patients usually experience.
Are there any risks and side effects?
All medical procedures have some risks associated with them. Flumazenil has been associated with seizures in about 1-3 % of patients when it is used for treating an overdose. If a patient takes a large overdose of a benzodiazepine, most ER physicians give a large dose of Flumazenil to quickly reverse the benzodiazepine. About 1-3 % of these patients will have a seizure. However the doses we use in our protocol are less than one percent of those given for the overdose patients. We have not seen any seizures in our patients up to this point.
How do patients feel during the detox?
Most of our patients feel quite comfortable during the detoxification. Most patients have not experienced severe withdrawal symptoms. They have generally eaten and slept well throughout the whole 7 days. They have also not experienced severe post acute withdrawal symptoms after the detoxification is complete. A small number of patients have experienced an increase in withdrawal symptoms as the Flumazenil is pushing their benzodiazepines out of their system. We use medicines to help with any discomfort, and as the detoxification continues their withdrawal symptoms get better.
What happens after the detoxification?
After the detoxification some patients benefit from non-addictive medications to help with making sure anxiety and depression do not return. We always recommend counseling and support groups.